影响我院病案疾病编码准确性的相关因素及干预对策  

Related factors affecting the accuracy of disease coding in our hospital and intervention measures

作　　者：黄洁仪 谢旦 巫丽娟 HUANG Jie-yi;XIE Dan;WU Li-juan(Department of Medical Records and Statistics,Qingyuan Traditional Chinese Medicine Hospital in Guangdong Province,Qingyuan 511500,China)

机构地区：[1]广东省清远市中医院病案统计科,广东清远511500

出　　处：《中国当代医药》2020年第6期186-188,192,共4页China Modern Medicine

摘　　要：目的探讨影响我院病案疾病编码准确性的相关因素,并提出干预对策。方法选取2017年1月~2019年1月清远市中医院发生编码错误的100例病案资料。分析错误编码类型及错误原因,并据此提出干预措施。结果100例病案资料错误编码类型为主要诊断选择编码(32.00%)、肿瘤编码(28.00%)、疑难杂症编码(23.00%)、合并症编码(17.00%);100例病案资料编码错误原因为字迹潦草(20.00%)、书写不规范(13.00%)、主要诊断表述不明确(22.00%)、外部原因填写笼统(5.00%)、格式填写不当(8.00%)、编码人员专业素质低(12.00%)、编码操作程序不规范(12.00%)、编码字库不全面(8.00%)。结论主要诊断选择编码、肿瘤编码、疑难杂症编码、合并症编码是我院病案疾病编码错误的类型,我院病案疾病编码准确性与医师、编码人员及编码字库不全面相关,临床据此实施干预措施可提高疾病编码准确性,为医院临床工作提供参考依据。Objective To explore the related factors affecting the accuracy of disease coding in our hospital,and to propose intervention measures.Methods A total of 100 cases of coding errors in the Qingyuan Traditional Chinese Medicine Hospital from January 2017 to January 2019 were selected.The type of coding errors and the cause of the error were analyzed,and intervention measures was proposed accordingly.Results One hundred erroneous codes types include primary diagnostic selection code(32.00%),tumor code(28.00%),intractable syndrome code(23.00%)and complication code(17.00%).One hundred cases of coding errors were caused by poor handwriting(20.00%),unstandardized writing(13.00%),indistinct main diagnosis(22.00%),unclear external causes(5.00%),improper format(8.00%),poor qualified coding staffs(12.00%),non-standard coding procedures(12.00%),and incomplete word stock of code(8.00%).Conclusion The primary diagnostic selection code,tumor code,intractable syndrome code,and complication code are the types of disease coding errors in our hospital.The accuracy of disease coding in our hospital is not comprehensively related to physicians,coding staffs and word stock.Related intervention measures can improve the accuracy of disease coding and provide reference for clinical work.

关 键 词：病案 疾病编码 错误原因 干预对策 

分 类 号：R197.323[医药卫生—卫生事业管理]